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    <title>eTiQa Insurance Singapore - Online Payment</title>
    <link href="style/etiqa.css" rel="stylesheet" type="text/css" />

    <script src="js/creditcard.js" type="text/javascript"></script>

</head>
<body>
    <div id="etiqa_wrapper">
        <div id="etiqa_header">
            <div class="r_curve">
            </div>
            <img alt="Etiqa" src="images/etiqa_logo.gif" width="138" height="67" />
        </div>
        <div class="clear">
        </div>
        <div id="etiqa_form">
            <!--Last Updated >> 15/Feb/2011-->
            <form id="form1" onsubmit="return validateForm();" method="post" action="https://nera.i2pay.com.sg/ipsmerchwiz/trans/pg2ve.jsp">
            <h1>
                eTiQa Insurance Singapore Branch</h1>
            <fieldset>
                <legend>Online Payment Page</legend>
                <input type="hidden" name="merchantnumber" value="5000000081" />
                <input type="hidden" id="ordernumber" name="ordernumber" />
                <dl>
                    <dt>
                        <label>
                            Total $ (SGD)
                        </label>
                    </dt>
                    <dd>
                        <label>
                            <input type="hidden" id="amount" name="amount" />
                            <input type="hidden" name="currency" value="SGD" />
                            <b><span id="lblAmount"></span></b>
                        </label>
                    </dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            Email Address
                        </label>
                    </dt>
                    <dd>
                        <input type="text" id="email" maxlength="30" style="width: 250px;" name="email" /></dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            Name of the Card</label></dt>
                    <dd>
                        <input name="ccname" maxlength="30" id="ccname" type="text" /></dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            Card Type</label></dt>
                    <dd>
                        <p>
                            <label>
                                <input type="radio" name="rdoCardType" checked="checked" value="1" id="rdoVisa" />
                                Visa</label>
                            <label>
                                <input type="radio" name="rdoCardType" value="2" id="rdoMaster" />
                                Master</label>
                            <br />
                        </p>
                    </dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            Credit Card Number</label></dt>
                    <dd>
                        <input type="hidden" name="ccnumber" id="ccnumber" />
                        <input type="text" style="width: 50px;" onkeypress="restrictToNumbers(event)" maxlength="4"
                            name="txtCardNo1" id="txtCardNo1" />
                        -
                        <input type="text" style="width: 50px;" onkeypress="restrictToNumbers(event)" maxlength="4"
                            name="txtCardNo2" id="txtCardNo2" />
                        -
                        <input type="text" style="width: 50px;" onkeypress="restrictToNumbers(event)" maxlength="4"
                            name="txtCardNo3" id="txtCardNo3" />
                        -
                        <input type="text" style="width: 50px;" onkeypress="restrictToNumbers(event)" maxlength="4"
                            name="txtCardNo4" id="txtCardNo4" />
                    </dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            Card Expiry Date</label></dt>
                    <dd>
                        <input type="hidden" value="0" id="ccdate" name="ccdate" />
                        <select name="ddlMonth" id="ddlMonth" onchange="ChangeCCDate()">
                            <option value="0" selected="selected">mm</option>
                            <option value="01">01</option>
                            <option value="02">02</option>
                            <option value="03">03</option>
                            <option value="04">04</option>
                            <option value="05">05</option>
                            <option value="06">06</option>
                            <option value="07">07</option>
                            <option value="08">08</option>
                            <option value="09">09</option>
                            <option value="10">10</option>
                            <option value="11">11</option>
                            <option value="12">12</option>
                        </select>
                        -
                        <select name="ddlYear" id="ddlYear" onchange="ChangeCCDate()">
                            <option value="0" selected="selected">yyyy</option>
                            <option value="12">2012</option>
                            <option value="13">2013</option>
                            <option value="14">2014</option>
                            <option value="15">2015</option>
                            <option value="16">2016</option>
                            <option value="17">2017</option>
                            <option value="18">2018</option>
                            <option value="19">2019</option>
                            <option value="20">2020</option>
                        </select></dd>
                </dl>
                <dl>
                    <dt>
                        <label>
                            CVV No</label></dt>
                    <dd>
                        <input type="text" onkeypress="restrictToNumbers(event)" maxlength="3" id="cvv2"
                            name="cvv2" /></dd>
                </dl>
            </fieldset>
            <div class="clear">
            </div>
            <fieldset class="action">
                <input name="Confirm Payment" type="submit" class="float_btn" value="Confirm Payment" />
            </fieldset>
            </form>
        </div>
        <div class="clear">
        </div>
    </div>

    <script src="js/form.js" type="text/javascript"></script>

</body>
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